Fraud, Waste & Abuse

Fraud is knowingly and willfully executing, or attempting to execute, a scheme to obtain financial or personal gain (Example: billing for services not provided). The term does not include unintentional technical, clerical or administrative errors.

Abuse is any action that may result in one or more of the following: unnecessary costs to the healthcare system, improper payment for services, payment for services that fail to meet professionally recognized standards of care and services that not medically necessary (Example: billing excessive charges for services or supplies).

Fraud Protection and Prevention

The Plan's Special Investigations Unit (SIU) utilizes fraud detection software for medical and prescription claims, investigates any suspicious claims and reviews concerns from members and other sources regarding possible fraud and abuse.

Common concerns from members are suspicious phone calls and bills for services not received.

Suspicious Phone Calls

Example: You receive a call from someone claiming to be from the Plan and they ask for personal information like your social security number or financial information.

If you suspect a call may be a scam, do not give any personal or financial information.

Here are a few ways you can protect yourself against future calls:

• Enroll in the National Do Not Call Registry - donotcall.gov or 888.382.1222
• Enroll in the Texas Do Not Call list - TexasNoCall.com
• Report these numbers as suspected scam - texasattorneygeneral.gov (under Consumer Protection section of the website) or call 800.621.0508
• Report these numbers to the Federal Trade Commission - reportfraud.ftc.gov or 877.382.4357

Bills for Services You Did Not Receive

Example: You see a service on your Explanation of Benefits (EOB) or get a bill for something you did not receive.

If you receive a bill for services you do not recognize, it is best to contact your provider first. It may be a simple error that can be easily corrected. If you still suspect fraudulent activity after speaking with your provider, you can contact the Plan using one of the following:

HelpLine
The HelpLine is a confidential means of reporting.

Compliance Officer

You may also contact the Texas Department of Insurance (TDI) using one of the following:

Here are a few ways you can identify services billed to the Plan:

• Review your Health Plan Explanation of Benefits (EOB) to ensure accurate dates of service, name(s) of providers and services billed.
• Review bills and EOBs on the MyBSWHealth app: App Store | Google Play.

Potential Schemes Related to COVID-19

Scammers are using telemarketing, text messages and door-to-door visits, as well as, social media to conduct their fraudulent activities. These individuals are offering COVID-19 tests, grants and prescription cards in exchange for personal information to benefit themselves and harm the public.

Ways to protect yourself from fraud and abuse schemes:

• Never share information with unknown individuals. This should include date of birth, social security number, Medicaid or Medicare numbers, healthcare details, financial or other personal identifiable information. Sharing this type of information can lead to identity theft.
• Review your explanation of benefits (EOB) or claims/billing information in MyBSWHealth for suspicious activity or claims.
• Ignore offers or advertisements for COVID-19 testing or treatments on social media.
• Never post photos of your COVID-19 vaccination cards on social media.
• Do not open links in text messages from unknown individuals.
• Do not trust any unexpected calls or visitors offering COVID-19 tests or supplies.
• Do not pay anyone to speed up your vaccine eligibility.
• Report suspected fraud to the plan HelpLine: 888.484.6977